These results do not suggest a functional role for tonic NO production in the frequency-dependent depression of contraction or beta-adrenoceptor desensitisation in myocytes from failing human ventricle.

We report a rare combination of congenital cardiac malformations in an asymptomatic adult--a bicuspid aortic valve and double fibrous diverticula of the left ventricle. We describe the presentation and course of events followed by a brief discussion of ventricular diverticula and the management of this rare combination of anomalies.

The ECG is abnormal in over 70% of patients with pulmonary embolism. Certain ECG abnormalities have been observed to return to normal after treatment. This case report describes an instructive ECG series in a patient with massive bilateral pulmonary embolism as shown by spiral computed tomography. The initial ECG showed sinus tachycardia with P pulmonale, although atrial tachycardia could not definitively be excluded. The patient had an increased troponin I concentration and echocardiographic evidence of right ventricular dysfunction and underwent thrombolysis with alteplase and anticoagulation with warfarin. P wave amplitude gradually decreased throughout admission and her tachycardia resolved. This may reflect a reduction in right atrial strain after treatment. This phenomenon has apparently not been described in this setting. The significance of ECG changes and the role of thrombolysis in pulmonary embolism are briefly discussed.A 61 year old retired nurse was referred by her general practitioner to the casualty department with breathlessness and central chest tightness, which was pleuritic and not associated with palpitations or autonomic symptoms. She had no cough or haemoptysis. For the preceding nine months she had also noted a swollen, tender left leg, in which she was known to have varicose veins. She took hormone replacement therapy (HRT) for post-menopausal symptoms. She had no other risk factors for venous thromboembolism or ischaemic heart disease. The patient was ambulant and independent with respect to activities of daily living. She was a non-smoker and only occasionally drank alcohol.On examination, her temperature was 37.8˚C. Heart rate was 140 beats/min, and blood pressure was 140/80 mm Hg. Jugular venous pressure was not reported to be increased. Heart sounds were normal. Arterial blood gases on air were within normal limits, with oxygen saturation of 99% on air. Her respiratory rate was 16 respirations/min. Her chest was clear to auscultation. There was bilateral pitting oedema, more so in the left leg, in which there was evidence of varicose veins. The left leg was not tender to palpation and was not erythematous. The chest radiograph and other examination were unremarkable.Blood results were as follows: haemoglobin 8.25 mmol/l, white cell count 3.6 6 10 9 /l, platelets 266 6 10 9 /l, C reactive protein 20.1 mg/l; sodium 134 mmol/l, potassium 4.2 mmol/ l, urea 4.9 mmol/l, creatinine 73 mmol/l; albumin 36 g/l, total protein 68 g/l, alkaline phosphatase 108 IU/l, bilirubin 3 mmol/l, alanine transaminase 113 IU/l; thyroid stimulating hormone 31 mIU/l; and free thyroxine 11.7 pmol/l.A screening echocardiogram showed a dilated hypokinetic right ventricle. A working diagnosis of pulmonary embolism (PE) was made. Subcutaneous enoxaparin and analgesia were administered, and antiembolic stockings were applied. HRT was stopped. The initial ECG showed a tachycardia with tall P waves and low voltage QRS complexes (fig 1). Since atrial tachycardia was considered in the differential diagnosis, adenosine ...

A 56-year-old man with a previous deep venous thrombus presented with dyspnoea after a leg massage. A transthoracic echocardiogram demonstrated a "worm-shaped" right atrial embolus, most probably a femoral cast. A pulmonary artery angiogram confirmed a large wedge-shaped perfusion defect caused by a pulmonary embolus. There are previous case reports about leg massage causing pulmonary emboli but this is the first reported event where the thrombus has been visualised directly. Also, it demonstrates the important role that echocardiography plays in pulmonary embolus.

Cardiac cephalalgia is a migraine-like headache that occurs during episodes of myocardial ischaemia. Clinical characteristics of the headache vary widely but are often severe in intensity, worsen with reduced myocardial perfusion and resolve with reperfusion. It can present along with typical symptoms of angina pectoris, although not always. We present a 64-year-old man with a 6-month history of severe, non-exertional headaches occurring with increasing frequency. A resting ECG showed ST elevation in the inferior leads. His serum troponin I was not elevated. Coronary angiography showed severe stenosis of his right coronary artery, which was successfully stented by percutaneous coronary intervention. He remains headache free at 2-year follow-up.